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Category: 3. Toddlers

We all can picture our babies chewing on their fingers and toys and drooling before getting their first tooth. But what other symptoms do incoming primary teeth cause?

Nearly everything in the past has been blamed on teething, including seizures, meningitis, and tetanus. According to an article in Pediatrics in Review (April 2009), teething was listed as the official cause of death in about five thousand infants in England in the early 1800s. In France from 1600 to 1900, fifty percent of all infant deaths were blamed on teething!

Despite scientific evidence to the contrary, people still blame teething for numerous maladies.

Here are symptoms which are NOT caused by teething that parents should be aware of:

·Teething does not cause fever over 101 degrees F. Fever of this height or higher indicates infection somewhere. Maybe a simple viral infection such as a cold, or a more severe infection such as pneumonia, but parents should NOT assume that their baby’s fever over 101 F is caused by teething. These babies could be contagious. Parents should not expose them to others with the false sense of security that they are not spreading germs.

·Teething does not cause diarrhea severe enough to cause dehydration. If a child has severe diarrhea, then he most likely has a severe stomach virus or another medical issue.

·Teething does not cause a cough severe enough to cause increased work of breathing. Babies make more saliva around four months of age and this increased production does result in an occasional cough. But babies never have breathing problems or a severe cough as a result of teething. Instead, suspect a cough virus or other causes of cough such as asthma.

·Teething does not cause pain severe enough to cause a change in mental state.

Some children get crankier as their teeth erupt and cause their gums to swell and redden. But, if parents cannot console their crying/screaming child, the child likely has another, perhaps more serious, cause of pain and needs an evaluation by his or her health care provider.

Just from a logic standpoint, if teething causes symptoms as babies get their primary teeth, shouldn’t incoming permanent teeth cause the same symptoms? Yet I’ve never heard a parent blame teething for a runny nose, rash, cough, fever, or general bad mood in an eight, nine, or ten year old child who is growing permanent teeth.

Maybe these parents are too busy bemoaning the cost of early orthodontal work.

It’s only 3 p.m. on a Saturday and one of my children is in the shower for the second time today washing off the pollen which has turned her face into a puffy, slimy raspberry. It’s that beautiful time of year when the blooming flowers trigger allergic symptoms such as runny noses and red itchy eyes.

In addition to washing pollen off your child’s body, you can make some changes in your child’s environment to help decrease allergic reactions to the “great” outdoors. For one, turn on the air conditioner and close the windows to limit the outdoors from entering your child’s bedroom. Also, have your child wash her hands as soon as she comes in from playing outside to decrease the chances of her rubbing allergens into her eyes and nose.

Many kinds of medications can help allergy symptoms. The most commonly used oral medications are the antihistamines. These medicines work by limiting the “histamines” your body makes in response to allergies. Histamine causes itchy skin, red eyes, and runny noses. Examples of antihistamines are diphenhydramine (brand name Benedryl), loratadine (brand name Claritin), cetirizine (brand name Zyrtec) and fexofenadine (brand name Allegra). The most common side effect of antihistamines is drowsiness, especially with older antihistamines such as diphenhydramine. Most antihistimines are now available over the counter.

Another allergy medicine heavily advertised is Singulair. This medicine is a leukotriene inhibitor which prevents the body from releasing another type of substance (leukotrienes) that causes allergy symptoms.

Decongestants such as phenylephrine or pseudoephedrine can help decrease nasal stuffiness. This is the “D” in “Claritin D” or “Allegra D.” However, they are discouraged in young children because of potential side effects such as rapid heart rate, increased blood pressure, and sleep disturbances.

Some of the above mentioned medicines can be taken together and SOME CAN NOT. Parents may inadvertently give more than one oral antihistamine simultaneously. Read the labels carefully for the active ingredients and do NOT give more than one oral antihistamine at a time. In contrast, most antihistamine eye drops and nose sprays can be given together with oral antihistamines.

Please consult your child’s health care provider to determine which allergy medications will best help your child this allergy season. A carefully thought out allergy plan can go a long way to helping your child’s allergy symptoms.

Sure beats taking five showers a day or having your nose removed for allergy season!

I admit to having no statistics on this observation, but as a pediatrician and a mom, I have observed that ear infections strike disproportionately on Friday nights. Have you observed this as well?

I wish children had some kind of external ear indicator that would flash “infection” or “not an ear infection” when they have middle of the night attacks of pain. Unfortunately, most people can not diagnose their child in the middle of the night. Even I can’t diagnose my own children at home because my portable otoscope, the instrument used to examine ears, died from overuse a year ago. However, there are ways to treat ear pain no matter what the cause.

Of course we all want to know the cause of our children’s pain. However, there is no danger in treating pain while we investigate the cause, or until daytime comes and pediatricians open their offices. Good pain relievers such as acetaminophen (brand name Tylenol) or ibuprofen (brand names Advil and Motrin), given at correct doses, will treat pain from any source. Treating pain does not “mask” any physical exam findings so go ahead and ease your child’s misery before going to your child’s health care provider. I feel bad for my young patients whose parents tell me, “We didn’t give him any pain medicine because we wanted you to see how much his ear is hurting him.”

Heat in the form of warm wet compresses or a heating pad will also help. Prop your child upright. If the pain is from an ear infection, the position will relieve pressure. Distraction such as a 2:00 am Elmo episode will also blunt pain.

Only about half of all patients seen in the office with ear pain or “otalgia” actually have a classic middle ear infection. Pain can stem from many sources, including the outer part of the ear. Swimmer’s ear, which is an outer ear infection (see swimmer’s ear blog post) is treated differently than a middle ear “inside” infection. Nearby body parts can also produce pain. Throat infections (pharyngitis), from strep throat (see strep throat posts) or viruses, often cause pain in the ears. Even pain from jaw joint strain and dental issues can show up as ear pain. Over the years I have sent several children straight from my office to the dentist’s office for treatment of tooth ailments masquerading as ear pain.

No article on ear pain would be complete without addressing“ear tugging.” Many babies by nine months of age discover their ears and then play with them simply because they stick out (I will leave to your imagination what boy babies tug on). Babies often tug on ears when they are tired. Therefore, tugging on ears alone may not indicate an ear infection, especially if not coupled with other symptoms.

Although ear infections are one of the most common ailments of childhood and most children have at least one ear infection by age three, remember that not all ear pain is caused by ear infections. In the middle of the night, and even in the middle of the day, it IS okay to give some pain relief before seeing your child’s health care provider.

Why ear pain always seems to awaken a child in the middle of the night, I’ll never know. All I know is that I have to remember to buy a new otoscope for home.

As I pack for an upcoming family vacation, I am reminded of the numerous questions over the years that parents have asked me about traveling with children. Often they ask, what is the best way to travel that will allow everyone to enjoy the vacation?

Ha,ha, I think to myself.The real answer is to hire a sitter or enlist grandparents to babysit and leave the kids at home. My husband and I always refer to family vacations as “family displacements.”

No, really, family vacations are wonderful experiences as long as you hold realistic expectations. First you have to get there.

Easier said than done.

When traveling by air, parents wonder if they should bring a car seat for the plane. Young children who sit in a car seat in the car should sit in a car seat in an airplane. Unfortunately, not all car seats fit into the airplane seat properly. The best advice I can give is to bring your car seat and make an attempt to fit it properly. If it doesn’t fit properly, you will still need it for the car ride from the airport after you arrive at your destination. Not all car rental facilities provide car seats.

Another question I am frequently asked about long plane rides is “Should I give my child Benadryl (diphenhydramine) so he/she will sleep through the flight?” Unfortunately, Benadryl’s reliability as a sleep aid is spotty at best. Most kids get sleepy, but the excitement of an airplane ride mixed in with a “drugged” feeling can result in an ornery, irritable child who is difficult to console. I advise against this practice. On the other hand, Benadryl can help motion sickness and is shorter acting than other motion sickness medications.

Ear pain during an airplane’s descent is also a common worry. Yes, it is true that ears tend to “pop” during the landing as the air pressure changes with altitude. Some young children (and their parents) find this sensation very unpleasant. However, most babies are lulled to sleep by the noise and vibration of an airplane and are unaffected. If your child is safely in a car seat, I do not advise taking him out of it to breastfeed during landing. Offer a pacifier if you feel he needs to suck/swallow during the landing, and offer an older child a snack so she can swallow and equalize ear pressure if she seems uncomfortable during the landing.

Speaking of food, try to carry healthy snacks rather than junk food when traveling. Staying away from excessively salty or sweet food will cut down on thirst. Also, keep feeding times similar to home schedules in order to prevent toddler meltdowns.

Remember that young children hate to wait for ANYTHING and that includes getting to your destination. Bring along distractions that are simple and can be used in multiple ways. For example, paper and crayons or pencils can be used for: coloring, drawing, word games, origami, tic-tac-toe, math games, etc.

When traveling internationally, check the Center for Disease Control website www.cdc.gov for the latest health advisories for your travel destination. Do your research several weeks in advance because some recommended vaccines are available only through travel clinics. Also, some forms of malaria prevention medicine need to be started a week prior to travel.

Please refer to our “Happy, Healthy Holiday” blog post from 12/10/2009 for further information about keeping kids on more even keel during vacations. In general, attempt to keep eating and sleeping routines as similar to home as possible. Also remember to wash hands often to prevent illness during travel. Finally, locate a pediatrician or child friendly hospital ahead of time in case illness does strike. Unfortunately, most illnesses cannot be diagnosed by your child’s health care provider over the phone.

While traveling with young children can seem daunting, the memories you create for them are well worth the effort. And it DOES get easier as the kids get older. Now I can laugh at the image of my husband with two car seats slung over his back lugging a large diaper bag and a carry-on, leading my preschooler struggling with his own backpack filled with snacks and air plane distractions, while I am balancing two non-walking twin babies, one in each arm, as we all take our shoes off for the airplane security checkpoint.

Concerned parents ask me this question, and I am relieved to be able to tell them “NO.”

Amazingly, most of the autism/vaccine hoopla can be traced to one very small report.

In 1998 a doctor named Andrew Wakefield published a paper in a well respected British medical journal called The Lancet. He said that in his study of twelve children who were patients in a GI (Gastroenterology) clinic, eight of them had evidence of abnormal intestines and abnormal behavior that began after they received the MMR vaccine. He wondered if the combined MMR vaccine may have triggered abnormalities in the gut, allowing unspecified toxins to leak out from the gut, causing brain damage.

Unfortunately, this one small paper involving 12 children caused huge controversy about the safety of vaccines. Many parents lost confidence in the very vaccines that were so successful at protecting the lives of their children.They stopped vaccinating and caused the measles rate to increase. For evidence of this please see:

On February 6, 2010, The Lancet published a retraction of this paper because the study design was flawed and thus any conclusions cannot be reliable. Specifically, the UK General Medical Council’s Fitness to Practise Panel, after investigations, concluded that the children in the study were not “consecutively referred,” meaning that they were not “random samples” as stated in the paper.

In addition, the panel discovered that Dr. Wakefield did not have permission from any institutional review board (panels that review the ethics of research done on people) to perform the lumbar punctures, MRIs, EEGs, endoscopies, and intestinal biopsies that he conducted on the children whom he studied.

Despite the original study being flawed, a question about a connection between MMR and autism had been raised. In the years since 1998, scientists performed subsequent studies to see if the MMR vaccine might have a link to autism. No association was found. These studies involved thousands of children and showed that the rate of autism in vaccinated children is THE SAME as the rate of autism in unvaccinated children. To read these articles as well as the original article that caused the controversy, you can go to www.TheLancet.com and register to view the articles for free.

I urge all parents reading this blog post to speak with your child’s health care provider if you have ANY doubts about vaccinating your children. In addition, if you are going to conduct your own research on this subject on the Internet, I urge you to consult the following credible sites:

Vaccines save lives. Unfortunately, for those too young to be vaccinated, those who have immune system diseases, and those who do not receive immunizations, vaccine preventable diseases still can potentially cause severe illness and death.

Just last night my ten year old sounded the “MOMMY, MOMMY!!!” alarm in the middle of the night. Almost without opening my eyes I went to his room and calmly walked him to the bathroom where he emptied his bladder with gusto and went right back to bed. Witness: A nightmare with a purpose.

Ever wonder when you, the parent, get to sleep through the night? Now that your child has graduated from the crib, tune into this podcast to learn how to handle situations that sabotage sleep in children: nightmares, night terrors, night wanderings, and bedwetting.

My sister-in-law was startled when brown spots began to appear on her preschooler’s teeth. A trip to the dentist revealed that my nephew had eleven cavities, the result of constantly drinking juice as an infant and toddler. Unfortunately, time in the operating room was required to fill all the rotten spots. Today our guest blogger, Dr. Paria Hassouri, answers frequently asked questions on infant dental care. Starting care as an infant can prevent your child from ending up like my nephew with a mouthful of cavities. Dr. Hassouri is a board certified pediatrician who completed her training at the Cleveland Clinic Foundation. She has been in practice for seven years and is with Cedars Sinai Medical Group in Beverly Hills, California. She is currently writing abook about the experience of pediatrician moms across the United States. – Dr. Lai

When do I need to start brushing my baby’s teeth?

You should start brushing your baby’s teeth as soon as they come out. You can either use a clean moist washcloth or a soft baby toothbrush to do this. Before this point, many pediatricians advocate wiping your infant’s gums with a washcloth a couple times a day.

While plain water is enough to clean the teeth and gums, you can also use a small amount of fluoride-free toothpaste. Flossing should begin anytime there is tight contact between the teeth, particularly when the molars come in.

When will my baby get his/her first tooth?

While most babies will get their first tooth between 6 to 10 months, your baby may not get his/her first tooth until 15 to 18 months.

What is “baby bottle tooth decay” and how do I prevent it?

Baby bottle tooth decay is caused by frequent and long exposure of an infant’s teeth to liquids that contain sugar. The sugar penetrates the gums and affects the teeth even while they are below the surface. Sugar-containing drinks include milk and formula (even breastmilk), fruit juice, and other sweetened drinks. Putting a baby to bed for naps or at night with a bottle increases the risk. And again, remember that your baby does not need any juice.

When does my baby need to first see a dentist?

While the American Academy of Pediatric Dentistry recommends dental visits starting at age one, you can ask your pediatrician when he/she thinks that your baby should first see the dentist. If you are already following a good dental care regimen which includes brushing your baby’s teeth regularly and not letting your baby fall asleep with a bottle, your pediatrician may say that you can wait longer for the first dental visit.

What to I do if my baby dislikes or refuses to let me brush his/her teeth?

Even if your child resists brushing, it is still very important to brush the teeth twice a day. You can try brushing in front of a mirror or taking turns with your child. You can also try having your child hold a larger, thicker handled toothbrush while you use a thinner handled toothbrush to brush the teeth. In this way, the thicker toothbrush acts as a “door stop” that your child can bite on to keep his mouth open while you follow through with the thinner toothbrush. Finally, you can try blowing bubbles or singing a special song while you are brushing your child’s teeth. That way your child associates this special activity with tooth brushing; but keep in mind that this only works if you reserve the blowing bubbles or other special song for tooth brushing.

What should we do if we don’t have fluoride in our water ?

If your water does not contain fluoride, ask your pediatrician or dentist about fluoride supplements starting at six months old.

Remember Elmer Fudd from the Bug Bunny cartoons? He was the hunter who would say “Where’s the wascally wabbit?” instead of “Where’s the rascally rabbit?” Think how frustrated Elmer was as a kid when his parents and teachers didn’t understand him.

Unclear speech or lack of speech development can be a sign of hearing loss or an inability to communicate (autism, retardation or developmental delay). Amy King, MA, CCC-SLP with over 12 years as a speech therapist outlines important speech and language milestones to watch for:

Receptive Language Milestones- what your child understands (children should be doing these things by the time they reach the year marker)

By the time they are:

1 year: shakes head to respond to simple questions such as “Want milk?” and identifies some body parts

2 years: Follows 1 step directions- “Go get the ball.”

3 years: Follows 2 step directions- “Go get the ball and give it to daddy.”

4 years: Understands if/then- “If you pick up your toys, then you can help Mommy make a cake.”

5 years: Follows 3 step directions- “After you wash your hands, get the napkins and put them on the table.”

Expressive Language Milestones- what your child is able to say

1 year: 1 word

2 years: 2 word sentences- two words with one meaning such as “thank you” does not count. Expect phrases such as “mommy up” for “mommy, pick me up.”

Speech Milestones- phonetics (sounds should be produced accurately and consistently in words and phrases)

By the time they are:

3 Years: sounds of the letters: m, b, p, h, w, n, f,

4 Years: t, k, g, ng, s, r, sh

5 Years: z, l, v, y, th, wh, ch

6 Years: j, st, br, cl, r (by now if not before)

Speech Intelligibility -how well strangers understand your child

2 Years: at least 25%-50% of what your two year old is saying

2 ½ Years: at least 60%-75% of what your two and a half year old is saying

3 Years: at least 75%-90% of what your three year old is saying

4 Years: at least 95% of what your four year old is saying

Fluency- stuttering

Stuttering is normal in the preschool years. Be sure to give the child time to say what she is trying to say. Dr. Lai likes to think of a preschool stutterer as a child whose mind is thinking faster than he can move his mouth. If stuttering lasts more than 6 months and is accompanied by facial contortions, grimaces, or repetitive body movements, speak to a medical professional.

Red flags that always need further workup:

oDoes not coo by 4 months of age

oDoes not babble by 9 months of age

oChild does not respond to his/her name by 9 months of age

oChild does not look at you, others or objects upon request by 9 months of age

Whether you love or hate the pacifier, at some point, to avoid the possibility of dental and speech articulation impairment, your child needs to wean. Besides, it’s nice to see your child’s entire face. The easiest time to wean is usually around two to three years old. At that point, your child’s dependence on sucking for self-comfort begins to lessen and he begins to want to dissociate himself from being a “baby.”

Now that it’s the New Year, here are some ways to say bye-bye to the binkie, if this is on your child’s (or your) resolution list.

Throw the pacifier across the room and entice your child to say with you, “Yucky, binkies are for babies.”

Restrict pacifiers to specific places such as your home, crib, or bed

Take a “Binkie finding hunt” with your child and gather all the binkies into a basket. Have the binkie fairy come overnight, take the basket, and leave a present in the morning. Alternatively, one set of parents told me that they told their child that they were gathering binkies for babies who didn’t have any.

If giving your child a pacifier is part of your bedtime routine, start to introduce something else such as a special blanket or stuffed animal.

Sometimes as parents, we are the ones who have to be weaned. When your child is upset, do not automatically pop a binkie into your child’s mouth. Seek other ways to help your child calm himself

Vow to yourself not to buy new pacifiers at the grocery store. Gradually the pacifiers left in the house will disappear or the mold on them will prompt you to throw them away.

Cut a small hole in the tip of the nipple- the binkie will not “be the same.” Tell your child that the binkie is broken and throw it away.

Vacations disrupt schedules. Therefor, sometimes in an unfamiliar bed, children wean habits. Conveniently forget the binkie while going on vacation and do not introduce it on return home.

By age three, most kids appreciate the value of a good bribe. Offer them a reward for going a whole week (or at least 3 days) without the binkie. One night doesn’t count because often the second night is more difficult for the child than the first when he is giving up the binkie. Once you have gone a week, the child will have no desire to go back. Just make sure you have disposed of every last binkie in your home so they will not have reminders of the “good old days.”

Mothers and fathers of twins know that parenting twins is not “twice the work” of singletons. Parenting twins is “EXPONENTIALLY the work” of parenting singletons. Think “singleton, squared.” I know. Not only do I care for twins (and triplets!) in the office, but also I have a set at home.

Discipline is tough. Twins squabble just like other siblings. The difficulty lies in that twins are at the exact same developmental stage as each other. In contrast, when you have a two-year-old and a four-year-old child, for example, you expect the two-year-old to not understand sharing or turn taking and you expect the four-year-old to understand both. Then, you can patiently explain to a four-year-old, “Well, if your younger sister has the doll, and you want it, you can make her very interested in another toy. Then, trade her the toy for the doll.”

When you have two-year-olds fighting over the same toy, you have few options. You can force turn taking, which always involves crying (for the one who is waiting for her turn). You can put the toy in time out which causes both twins to cry. Or you can put both twins in time out which, to help you visualize, can be like putting two angry Houdini octopi into a net together.

Turn taking can be taught using the “count to ten” method. Take this scenario: both twins “need” the same red car at the exact same time. You know that the only reason twin B wants the car is because twin A has the car (this is the same logic as for any sibling: “I covet what you have because you have it.”) You give the car to twin A and stay with twin B, hold his hand, and say, “When we get to ten, your brother will give the car to you.” Then you slowly count out loud to ten. If twin A does not give up the car, then gently take the car from him and say, “Now your brother gets the car until we get to ten.” Stay with twin A while twin B plays with the car and you count out loud to ten. Keep switching off until one brother says “I don’t want it” or simply gives the car away by the time you get to 3 or 4 in your count.

Using the “count to ten” method teaches several lessons: 1) how to count to ten, 2) how to wait your turn, and 3) that fairness matters in your home.You also convey to your child that you will not abandon a crying, frustrated two-year-old. The textbooks say that two-year-olds are young to learn to share.However, twins must learn how to share. And you know what? This method works.

When my twins started preschool at two-and-one-half years old, I warned their teacher that if she saw either of my twins standing next to a classmate and counting to ten slowly, loudly, and deliberately, that my child would expect that child to hand over whatever toy she had when my child got to ten! I had to prep my twins that home rules may differ from classroom rules.

What about time out? Time out doesn’t work as well with toddler twins. If one twin is in time out, the other twin will sabotage the time out by making a raucous. One time, I put one of my twins in time out for biting the other one.Because the biter was crying, the victim startled me when he also started crying and yelling “Let him out of Time Out, Mommy!”One way around this is to put the toy that precipitated the squabble in time out instead of the child (one minute per year of the twin’s age).

Even at the end of the day, discipline for twins differs.For twins who share a bedroom, every night is a slumber party. When my twins became old enough to talk to each other before falling asleep, I moved their bedtime earlier to allow them extra time to talk. I found their conversations too cute to interrupt and didn’t have the heart to enforce sleep time. Plus I like to think that it made up for any bickering (ok, fighting and tears) that occurred during that day and allowed for extra bonding time. Like so many other aspects of parenting, sometimes you just have to go with the flow.